Vote Smart's Synopsis:

Vote to concur with Senate amendments and pass a bill that establishes a statewide, integrated managed care program for all Medicaid services.

Highlights:

• Establishes a statewide, integrated managed care program for all Medicaid services, including long-term care services (Sec. 5).

• Requires Medicaid recipients enrolled in the managed care plan to pay a portion of the premium of $10 per month as a condition of Medicaid eligibility, provided that the Agency for Health Care Administration receives federal approval to implement this requirement (Sec. 13).

• Authorizes the Agency for Health Care Administration to apply for waivers of applicable federal laws and regulations necessary to implement the managed care program (Sec. 5).

• Requires all Medicaid recipients to receive covered services through the statewide managed care program, except for (Secs. 6 & 13):
• Women eligible only for family planning services;
• Women who are eligible only for breast and cervical cancer services;
• Individuals eligible for emergency Medicaid for undocumented immigrants;
• Children receiving services in a prescribed pediatric extended care center;
• Individuals who have other creditable health care coverage, excluding Medicare;
• Individuals residing in residential commitment facilities operated by the Department of Juvenile Justice or mental health treatment facilities;
• Individuals eligible for refugee assistance;
• Individuals who are residents of a developmental disability center; and
• Individuals enrolled in the home and community based services waiver program.

• Establishes 11 regions throughout the state that will have separate eligible plans to provide services in the Medicaid managed care program (Sec. 7).

• Defines an "eligible plan" as any one of the following (Sec. 3):
• A health insurer;
• An exclusive provider organization;
• A health maintenance organization;
• A provider service network;
• An accountable care organization authorized under federal law;
• The Children's Medical Services Network;
• Medicare Advantage Preferred Provider Organizations, Special Needs plans, and Provider-sponsored organizations; or
• The program of All-Inclusive Care for the Elderly.

• Authorizes the Agency for Health Care Administration to negotiate the rates or fee for service payments to health care providers with each eligible plan (Sec. 7). -Requires eligible plans to provide or secure the following (Sec. 8):
• Compensation for physicians;
• Payments for emergency services; and
• Access to care for both adults and children.

• Requires each eligible plan to establish (Sec. 14):
• A medically approved smoking cessation program;
• A medically directed weight loss program; and
• A medically approved alcohol or substance abuse recovery program.

• Specifies that Medicaid recipients shall have 30 days to choose and enroll in an eligible plan, and shall have 90 days after enrollment to changes plans (Sec. 10).

• Limits eligibility for the long-term care managed care plan to individuals who are (Sec. 19):
• 65 years of age or older, or age 18 or older and eligible for Medicaid by reason of a disability; or
• Determined by the Comprehensive Assessment Review and Evaluation for Long- Term Care Services program to require nursing facility care.

• Authorizes providers to limit the long-term care managed care plans they join, however nursing homes and hospices that are enrolled Medicaid providers must participate in all eligible plans selected by the Agency for Health Care Administration in the region in which they are located (Sec. 23).

• Authorizes long-term care managed care plans to negotiate mutually acceptable rates, methods, and terms of payment with providers (Sec. 23).

• Requires the managed care plan to share profits with the state as follows (Sec. 8):
• 100 percent of income up to and including 5 percent of revenue shall be retained by the plan;
• 50 percent of income above 5 percent and up to 10 percent shall be retained by the plan, and the other 50 percent refunded to the state; and
• 100 percent of income above 10 percent of revenue shall be refunded to the state.

• Prohibits the Agency for Health Care Administration from selecting plans in the same region for the same managed care program that have a business relationship with each other (Sec. 7).

• Requires eligible plans to establish an internal health care quality improvement system, incorporating enrollee satisfaction and disenrollment surveys and incentives and disincentives for network providers (Sec. 8).

• Requires eligible plans to reimburse the Agency for Health Care Administration for the cost of enrollment changes and other transition activities if the plans reduce enrollment levels or leave a region before the end of a contract term (Sec. 8).

• Requires the Agency for Health Care Administration to begin implementation of the statewide managed medical assistance program by January 1, 2013, and complete implementation in all regions by October 1, 2014 (Sec. 12).

• Requires the Agency for Health Care Administration to begin implementation of the statewide long-term care managed care program by July 1, 2012, and complete implementation in all regions by October 1, 2013 (Sec. 19).

• This act is effective July 1, 2011 (Sec. 29).

Full Bill Text

Vote Smart's Synopsis:

Vote to pass a bill that establishes a statewide, integrated managed care program for all Medicaid services.

Highlights:

• Establishes a statewide, integrated managed care program for all Medicaid services, including long-term care services (Sec. 5).

• Requires Medicaid recipients enrolled in the managed care plan to pay a portion of the premium of $10 per month as a condition of Medicaid eligibility, provided that the Agency for Health Care Administration receives federal approval to implement this requirement (Sec. 13).

• Authorizes the Agency for Health Care Administration to apply for waivers of applicable federal laws and regulations necessary to implement the managed care program (Sec. 5).

• Requires all Medicaid recipients to receive covered services through the statewide managed care program, except for (Secs. 6 & 13):
• Women eligible only for family planning services;
• Women who are eligible only for breast and cervical cancer services;
• Individuals eligible for emergency Medicaid for undocumented immigrants;
• Children receiving services in a prescribed pediatric extended care center;
• Individuals who have other creditable health care coverage, excluding Medicare;
• Individuals residing in residential commitment facilities operated by the Department of Juvenile Justice or mental health treatment facilities;
• Individuals eligible for refugee assistance;
• Individuals who are residents of a developmental disability center; and
• Individuals enrolled in the home and community based services waiver program.

• Establishes 11 regions throughout the state that will have separate eligible plans to provide services in the Medicaid managed care program (Sec. 7).

• Defines an "eligible plan" as any one of the following (Sec. 3):
• A health insurer;
• An exclusive provider organization;
• A health maintenance organization;
• A provider service network;
• An accountable care organization authorized under federal law;
• The Children's Medical Services Network;
• Medicare Advantage Preferred Provider Organizations, Special Needs plans, and Provider-sponsored organizations; or
• The program of All-Inclusive Care for the Elderly.

• Authorizes the Agency for Health Care Administration to negotiate the rates or fee for service payments to health care providers with each eligible plan (Sec. 7). -Requires eligible plans to provide or secure the following (Sec. 8):
• Compensation for physicians;
• Payments for emergency services; and
• Access to care for both adults and children.

• Requires each eligible plan to establish (Sec. 14):
• A medically approved smoking cessation program;
• A medically directed weight loss program; and
• A medically approved alcohol or substance abuse recovery program.

• Specifies that Medicaid recipients shall have 30 days to choose and enroll in an eligible plan, and shall have 90 days after enrollment to changes plans (Sec. 10).

• Limits eligibility for the long-term care managed care plan to individuals who are (Sec. 19):
• 65 years of age or older, or age 18 or older and eligible for Medicaid by reason of a disability; or
• Determined by the Comprehensive Assessment Review and Evaluation for Long- Term Care Services program to require nursing facility care.

• Authorizes providers to limit the long-term care managed care plans they join, however nursing homes and hospices that are enrolled Medicaid providers must participate in all eligible plans selected by the Agency for Health Care Administration in the region in which they are located (Sec. 23).

• Authorizes long-term care managed care plans to negotiate mutually acceptable rates, methods, and terms of payment with providers (Sec. 23).

• Requires the managed care plan to share profits with the state as follows (Sec. 8):
• 100 percent of income up to and including 5 percent of revenue shall be retained by the plan;
• 50 percent of income above 5 percent and up to 10 percent shall be retained by the plan, and the other 50 percent refunded to the state; and
• 100 percent of income above 10 percent of revenue shall be refunded to the state.

• Prohibits the Agency for Health Care Administration from selecting plans in the same region for the same managed care program that have a business relationship with each other (Sec. 7).

• Requires eligible plans to establish an internal health care quality improvement system, incorporating enrollee satisfaction and disenrollment surveys and incentives and disincentives for network providers (Sec. 8).

• Requires eligible plans to reimburse the Agency for Health Care Administration for the cost of enrollment changes and other transition activities if the plans reduce enrollment levels or leave a region before the end of a contract term (Sec. 8).

• Requires the Agency for Health Care Administration to begin implementation of the statewide managed medical assistance program by January 1, 2013, and complete implementation in all regions by October 1, 2014 (Sec. 12).

• Requires the Agency for Health Care Administration to begin implementation of the statewide long-term care managed care program by July 1, 2012, and complete implementation in all regions by October 1, 2013 (Sec. 19).

• This act is effective July 1, 2011 (Sec. 29).

Full Bill Text